HIV/AIDS - Research and Palliative Care
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Spiritual care may impact mental health and
medication adherence in HIV+ populations
Valerie U Oji 1–3
Leslie C Hung 3
Reza Abbasgholizadeh 1,4
Flora Terrell Hamilton 5
E James Essien 6
Evaristus Nwulia 7
1
Lifefountain Center Ministries Inc,
Houston, TX, USA; 2Feik School
of Pharmacy, University of the
Incarnate Word, San Antonio, TX,
USA; 3University of Texas, College
of Pharmacy, Austin, TX, USA;
4
University of Houston, Houston,
TX, USA; 5Administration, Family
& Medical Counseling Service, Inc.
(FMCS), Washington, DC, USA;
6
University of Houston Institute
for Community Health, Houston,
TX, USA; 7Psychiatry, Howard
University Translational Neuroscience
Laboratory, Washington, DC, USA
Correspondence: Valerie U Oji
Lifefountain Center Ministries Inc, 3880
Greenhouse Road 402, Houston, TX
77084, USA
Tel +1 281 492 1335
Email medgal8@gmail.com
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http://dx.doi.org/10.2147/HIV.S126309
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ORIGINAL RESEARCH
This article was published in the following Dove Press journal:
HIV/AIDS - Research and Palliative Care
28 April 2017
Number of times this article has been viewed
Objective: To explore a potential role for spirituality in medication-related needs assessment
for integrated care in chronically ill populations.
Method: A systematic literature review was conducted to explore the impact of faith beliefs on
health and/or medication adherence in individuals with depression and/or HIV+/AIDS. Retro-
spective electronic medical record review of adult HIV+ patients of an urban primary care clinic
with integrated mental health services was conducted, with Substance Abuse and Mental Illness
Symptoms Screener (SAMISS), major depressive disorder (MDD) incidence over the preceding
year, and history of contact with a spiritual advisor. A convenience sample was interviewed to
qualitatively assess potential medication therapy management needs and medication-related
problems. Another sample was examined utilizing the Daily Spiritual Experience Scale.
Results: The literature reports positive influence on health behaviors, coping and outcomes;
and poor medication adherence and treatment decisions due to patient passivity or resistance.
Spiritual advisor contact (not limited to a specific religion) was significantly associated with
MDD absence (1.7% vs. 15.3%, P<0.005) and inversely related to SAMISS, depression, and
poor health behaviors. Patient interviews reflected significance of faith in terms of insight and
acceptance of illness, the role or need for medications, coping, and medication adherence. An
illustrative model was designed based on the literature and data collection.
Conclusion: Spiritual assessment may help identify positive or negative influence on health.
Spiritual interventions could be beneficial in promoting adherence and positive health outcomes.
Further research is recommended.
Keywords: HIV+/AIDS, mental illness, depression, spirituality and health, African Americans 
Introduction
“Faith” includes a sense of connection to something bigger than ourselves, and it typi-
cally involves an innate search for meaning, purpose, and significance. Spirituality
represents a path the person takes in order to connect with his/her faith, as evidenced
by public practices (e.g., church attendance), prayer, religious commitment, coping, and
experiences.1,2 Religion provides an organized system of practices and beliefs in which
people engage, and it serves as a platform for the expression of spirituality.3 Spiritual-
ity, described as one’s non-physical essence or that aspect of individual beliefs, core
values, faith systems, and/or practices by which life meaning is assigned,1 is reported
to impact health. In the context of our study, these terms (spirituality, religion, and
faith) are used interchangeably to represent a broad belief in a higher power or source,
often outside of an individual’s control;2 although in fact individual spirituality may
exist apart from religious practice or faith traditions.
HIV/AIDS - Research and Palliative Care 2017:9 101–109 101
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Oji et al
Integrated care of physical and mental health conditions
has been increasingly recommended to improve patient
outcomes;4 this may be of particular value where there are
comorbid chronic conditions. Comorbidity of HIV+ and
depression reportedly could impact health outcomes with
clinical, economic, and/or humanistic consequences. Depres-
sion rates are higher among HIV+ individuals than the wider
US population; higher among HIV+ women, minorities, and
individuals with co-existing substance use.5–11 Depression has
been associated with poorer CD-4 T-cell counts, higher HIV+
viral loads, lower antiretroviral therapy (ART) adherence,
poorer prognosis, and higher mortality.12–15 These health out-
comes could be more profound in regions with inordinately
higher disease prevalence and vulnerable populations. Urban,
low-income African Americans (AAs) living in Washington
DC are the population of interest in this study and are dis-
proportionately vulnerable to the HIV+/AIDS epidemic.16
According to the DC Department of Health Annual Epide-
miology and Surveillance Report, although AAs account for
48.6% of DC residents, they account for 75% of individuals
living with HIV+ in DC. AA women account for 92.6% of
women living with HIV+ in DC.17
Spirituality and faith traditions have been reported as
significant to many individuals and could thus be a point of
health care intervention. In one multistate study of primary
care patients, a substantial proportion of surveyed patients
expressed that physicians should be aware of spiritual beliefs
or desire for spiritual interaction during health care visits.18
Many studies have linked depression to spirituality. It has
been shown that greater religiosity may contribute to devel-
opment of resilience in certain high-risk individuals having
a depressed parent.19 In another study, it was shown that
depressive episodes often lead to a search for spirituality,
which may be helpful in decreasing depression or becoming
less vulnerable to relapsing.20 In addition, spirituality was
found to be one of the significant factors decreasing depres-
sion in patients with alcohol use disorder.20 Furthermore, in
a neuroanatomical study, importance of religion or spiritual-
ity was associated with thicker cortices in the left and right
parietal and occipital regions, the mesial frontal lobe of the
right hemisphere, and the cuneus and precuneus in the left
hemisphere. This thicker cortex may assist individuals with
high familial risk of major depression to recover from com-
plications of depressive disorders.21
Spirituality and faith play a role in individuals of every
ethnicity and background, but may impact certain populations
more than others. In one survey conducted in 2001, AAs were
more likely to mention prayer as their most important source
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of influence in their HIV+ medication decisions compared
with Caucasians.22 For many patients, religious and spiritual
beliefs are at the core of their identity and their response to
sickness.23 Incorporating spiritual care into a patient’s chronic
therapy plan, especially considering our study population,
could be helpful to promote better adherence and ultimately
better health outcomes.
This study sought to explore the literature regarding the
relationship between spirituality and medication adherence,
particularly in depression and/or HIV+/AIDS; investigate
health outcomes; and identify medication-related needs
including spiritual care among HIV+ individuals at a
community-based clinic in Washington DC, which serves
predominantly low-income AAs.
Methods
Institutional review board (IRB) approval was obtained for
all aspects of the project from IntegReview and Howard
University IRBs. Informed consent was obtained for study
participant interviews and medical record reviews. An illus-
trative flow of methods is depicted in Figure 1.
Literature review
In our systematic review, three databases (PsycARTICLES,
MEDLINE, and CINAHL Plus) were utilized to conduct
literature searches for articles that highlighted the potential
impact of faith and spirituality on medication adherence in
patients who are undergoing long-term therapy. These peer-
reviewed studies were published between the years 1986
and 2015. Keywords such as “Impact” OR “Influence” OR
“Effects” AND “spirituality” OR “faith” OR “religion” AND
“depression” OR “HIV+” OR “AIDS” AND “medication”
OR “medication adherence” were used for our searches. A
total of 86 non-duplicate articles emerged from our searches.
After reviewing each abstract, we narrowed it down to 48
articles that were related to spirituality/religion/faith affect-
ing some form of health-related outcome in chronically ill
patients. We further narrowed down from the 48 articles, 33
that specifically related medication adherence to the HIV+/
AIDS and/or the depression population.
Medical record review
A retrospective review of adult HIV+ patients of an urban
primary care clinic with integrated physical and mental
health services had been conducted by means of electronic
medical record review, Substance Abuse and Mental Illness
Symptoms Screener (SAMISS), major depressive disorder
(MDD) incidence over the preceding year, and history of
HIV/AIDS - Research and Palliative Care 2017:9
Dovepress Spiritual care and mental health and medication adherence in HIV+ populations

Literature review
(Search through PsycARTICLES, MEDLINE, and CINAHL Plus databases)
Impact OR Influence OR Effects AND Spirituality OR Faith OR religion AND depression OR HIV OR AIDS AND
medication adherence
86 articles >>> 48 >>> 33: spirituality, medication adherence in HIV/AIDS and/or depression

Medical record review

(Review of clinic electronic medical records; n=147)
Depression screening, adherence, health behaviors, spirituality screening
SAMISS, medical record documentation of depression diagnosis or antidepressant use, patient self-
report of preceding 1-year depressive symptoms, patient self-report % ART adherence, drinking and drinking
discontinuation, prescription and illegal drug use, preceding 1-year spiritual advisor contact, DSES

Patient comprehensive medication review interviews

Medication-related problem identification (n=18)
Participant and staff interviews on clinic medication use processes
Emergent themes on adherence and medication use identified

Conceptual illustration: spirituality, adherence, and health

Synthesis: spirituality and health literature, literature review, investigator-published work, DSES, interviews,
Proposed spirituality and health associations with potential impact of faith-treatment incongruence
Figure 1 Methods.
Abbreviations: ART, antiretroviral therapy; DSES, Daily Spiritual Experience Scale.

contact with a s­ piritual advisor. This component of the clinic Depression screening

data emerges from a 3-year project “Adaptation of Effective
Depression Screening Tool for HIV+ African American
Urban DC Residents” aimed at the development of culturally
adapted interventions and improved treatment adherence in
community-based care for an urban, minority population.
The clinic provides behavioral health case management
and support groups, including spirituality group. During
early phases of the project, it was noted from multiple staff
mental health specialist interviews that patients would often
deny experiencing depressive symptoms during their routine
medical visits, were generally reluctant to discuss psychiatric
symptoms, but were much more open about mental health
issues during the clinic’s spirituality group.
The clinic population comprises primarily adult, urban,
African Americans. The SAMISS was used as a part of patient
intake by clinical personnel trained in its administration.
The SAMISS provides comprehensive evaluation of mental
health and substance abuse conditions in HIV+ patients. It is
a 16-question screening tool that takes under 15 minutes to
administer.24 Patients are screened for HIV+ status, sociode-
mographic, behavioral, and medical information that are
inputted into the electronic medical record. Patient CD-4+
counts are documented from blood draws collected on day
of intake and follow-up visits.
The retrospective medical record review was conducted for
158 HIV+ clinic patients to examine depression diagnosis
over a 2-year period. Patients had been interviewed as to
whether they had experienced, within the preceding year, a
diagnosis of depression or any depressive symptoms lasting 2
or more weeks. All participants were classified as MDD who
gave an affirmative response. The MDD classifications were
also verified or supported from the medical records by docu-
mented physician diagnosis or prescribed antidepressants.
Adherence, health behaviors, and
spirituality screening
ART adherence was evaluated for this population at intake by
asking what percentage of the time they took their treatments
as prescribed. Self-reported ART adherence classification
was as follows: ≥80% – adequate; ≤80 – inadequate. Problem
drinking was determined from SAMISS with the follow-
ing classification: >4 drinks per episode was categorized
as heavy. Difficulty with drinking discontinuation; social
problems related to drinking; and prescription and illegal
drug use over the preceding year were also noted. Patients
also self-reported whether they had received contact of any
form with a spiritual advisor within the preceding year. A
spiritual advisor was someone recognized by the individual

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Oji et al
as having spiritual training or leadership significant to that
individual’s beliefs to provide spiritual advice, support, or
counseling. A second sample was examined using the Daily
Spiritual Experience Scale (DSES), a 16-item self-report
measure of spiritual experience, for items reflecting strongly
in score and/or prevalence.
Patient comprehensive medication review
(CMR) interviews
At a follow-up focus group, 18 HIV+ individuals receiving
services at the clinic were interviewed to qualitatively assess
potential medication therapy management (MTM) needs
and medication-related problems (MRPs). Semistructured
interviews were conducted by the principal investigator to
perform a CMR and identify MRPs as a core component of
MTM. Patients were asked to name their medications and what
they had been prescribed for. MRPs were categorized, patient
responses to open-ended questions documented, and interview
notes reviewed for keyword coding and emergent themes.
Participants and staff were interviewed to gain understanding
of care delivery processes with respect to medication use.
Results
Only three studies examined medication adherence in HIV+/
AIDS patients suffering from depression and in relation to
spiritual involvement.25–27 One publication examined women
suffering from substance abuse and their adherence to ART.28
Depression is a common comorbidity for patients suffering
from an HIV+/AIDS diagnosis.25 In a 2013 study, Dalmida
et al. found that out of 292 patients living with HIV+/AIDS,
56.9% reported depressive symptoms.25 These patients with
concurrent depression report significantly poorer health out-
comes, including lower adherence to ART, lower CD-4+ cell
counts, and generally lower health-related quality of life. They
also found that the odds of being depressed were significantly
associated with lack of religious coping.25 In a study on ado-
lescents between 14 and 22 years of age with HIV+/AIDS,
they found that subjects with lower depression scores (using
the Beck Depression Inventory-II) had excellent adherence
compared to those with higher depression scores.26 The third
study in 2007 that involved HIV+ women with depression
in the Southeastern US concluded that coping by spiritual
activities was negatively correlated with missed medications
(P=0.005), along with availability of social support, coping
by positive thinking, coping by managing HIV+ disease, and
coping by focusing on the present.27
Another population we wanted to examine was the HIV+
patients who had substance abuse disorders. Substance abuse
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has been linked in the past with poor adherence to ART.29,30
One study focused specifically on adherence factors in
women on highly active ART who had concomitant substance
abuse issues. Most women in the study admitted that abuse
of illicit drugs and/or alcohol was the most important and
difficult barrier to taking medications. Many women claimed
that reliance on spirituality, God, and religion helped them
take their medications.28
In the majority of the 33 studies, spirituality had a
positive influence on health behaviors and outcomes. Faith is
often correlated with stronger social support,4 better coping
skills,25,27–38 and generally higher health-related quality of
life.25,39 In the Park and Nachman26 study mentioned above
with adolescents, they also saw that subjects with excellent
adherence had significantly higher religious belief scores
compared to those who had poor adherence (3.46±0.46 vs.
2.34±0.69, P<0.05).26 Similarly, a study conducted with
HIV+/AIDS patients in South Florida in 2009 demonstrated
that “the presence vs. absence of the belief ‘spirituality
helps coping with side effects’ was significantly associated
with better adherence and fewer symptoms”. Out of the 79
patients included in this study, about half of the participants
(38/79; 48%) reported spiritual/mind–body beliefs related to
treatment adherence.33 In a study in 2006, they focused on
African American and Puerto Rican patients in the US and
found that “social support predicted lower levels of negative
affect and greater spirituality, which in turn predicted self-
efficacy to adhere”.40
Adversely, a few studies found some levels of faith in
God could be damaging to medication adherence as patients
start to take a passive role in their own health care.33,34,41,42
In the same 2003 study,33 spirituality was noted to adversely
affect treatment decisions, with participants who believed
that their health was controlled by God/Higher Power being
4.75 times more likely to not take antiretrovirals compared
with those who did not express this control belief (P=0.032).33
Providers may need to use caution because some patients
seek more strength in God/religion than in themselves. This
could manifest as a strength or in contrast result in decreased
adherence to therapy as they start relying on an outside source
of control without applying inner strength and persever-
ance.34–36 Patients may also present with a view of God that
asserts that their diagnosis is a “punishment from God” or
“God’s will”.37,43,44 A study in 2011 showed that a view of
God as harsh/judgmental/punishing predicted faster disease
progression over 4 years in HIV+ individuals.44
Most of the studies reviewed were conducted in the
US, but we also evaluated some studies that took place in
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Africa,37,38,40,42,45–49 Asia,27,50 the Middle-East,51 and South
America.52 These regions are associated with a high preva-
lence of HIV+/AIDS, and oftentimes these individuals face
more barriers to adherence in the form of social stigma/
shame,37,38,42,46,47,52 medication access,37,38,42,47,52 and lack of
education on antiretrovirals.42,46,47 Social stigma presented
as a barrier to medication adherence because many patients
feared disclosing their HIV+ status to their family, friends,
and community. Patients who concealed their illness may not
feel comfortable taking their medications in front of others or
going to pick up their medications from clinics. Medication
access also proved to be a problem in these regions. Clinics
were often under-resourced to deal with the volume of patients,
which led to delays on clinic days and limited ART availabil-
ity to desperate individuals.37 Increased visits to clinics also
exposed patients to more embarrassment and stigma. False
beliefs and lack of education about ART also resulted in less
medication adherence. Patients may not be well informed about
the consequences of non-adherence, the efficacy of therapy,
and the potential for side effects.42 They tend to rely heavily on
complementary alternative therapies in the form of herbs, holy
water, and guidance from spiritual leaders.37,38,42,46,48
Retrospective medical record review
The SAMISS provides comprehensive evaluation of mental
health and substance abuse conditions in HIV+ patients. It is
a 16-question screening tool that takes under 15 minutes to
administer.24 SAMISS data for 147 patients were reviewed,
99% of whom were adult AAs. Contact with a spiritual advi-
sor over the preceding year was significantly associated with
the absence of MDD (1.7% vs. 15.3%, P<0.005). Figure 2
depicts ART adherence data for patients with and without an
MDD diagnosis. The groups with MDD receiving treatment
90
Non-adherent Adherent
80
70
60
50
40
30
20
10
0
% without MDD % treated MDD % untreated MDD
Figure 2 ART adherence features of study patients with and without MDD.
Abbreviations: ART, antiretroviral therapy; MDD, major depressive disorder.
HIV/AIDS - Research and Palliative Care 2017:9
Spiritual care and mental health and medication adherence in HIV+ populations
and without MDD were comparable in the levels of ART
adherence (53% vs. 48%, respectively) and non-adherence
(25% vs. 27%), while the level of ART non-adherence in
individuals with untreated MDD was 45% (P=0.51). Without
MDD and treated MDD patients also had more favorable
patterns of problem drinking absence (73% vs. 55%) than
individuals with untreated MDD (45% P=0.02). The number
of patients without MDD, treated MDD, and untreated MDD
was 89, 38, and 20, respectively. No significant differences
were found with gender, age, education, income, or substance
abuse patterns among the participants across MDD groups.
Figure 3 illustrates specific DSES items that scored high
among participants; specifically forgiveness, gratefulness,
positive emotions, and existential well-being. The study
population was found to have strong spiritual experiences in
areas of belief, relation and attachment or connection, posi-
tive emotions, well-being, and altruism. Statistical analysis
was conducted using STATA, version 12.
Patient CMR interviews
The majority of patients interviewed were unable to name
all of their medications; however, several were able to recall
with prompting or assistance. Few already had a printed
medication list, typically given to a patient during a CMR
and updated with routine MTM visits. All participants
except one preferred to use a local independent pharmacy
for their prescriptions; one used a mail order pharmacy with
the medications delivered to their primary care physician’s
(PCP’s) office. There was no prior experience with pharma-
cist provision of MTM. All medication questions, should
they arise, were reportedly directed to their PCP’s office.
Number of medications on patients’ regimens ranged from
2–22; patients were HIV+ and had at least one psychiatric
diagnosis. Potential MRPs identified included insight or
acceptance of their illness, non-adherence, medication costs,
untreated symptoms, and unwanted side effects. Statement
excerpt examples suggesting some influence of spirituality
include “I don’t claim any illness; by his stripes I’m healed
[…]”; “My healing is my testimony”; “I’m not sick, I’m
blessed”; the majority of participants made some reference
to their faith as a source of strength and coping. There were
complaints of having too many medications prescribed,
complaints such as unresolved insomnia, fatigue, pain or
concerns about medication toxicity. One patient reported
taking “medication holidays” to minimize side effects or
adverse reaction risk; several others reported discontinuing
and restarting medications for cost reasons. Emergent themes
were spirituality professed as significant; spirituality could
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Faith beliefs incongruent with treatment goals: non-adherence

• Social support and connection

Private
• Health behaviors /choices
religious or
• e.g., treatment adherence,
spritual
substance use, etc.
practice
• Health service utilization

Mental/physical
Spirituality health and
Spiritual • Forgiveness13 wellness
− Spiritual advisor
experiences • Gratefulness11 Immune function, mental health
e.g., less depression,
Source and/or • Positive emotions3,
anxiety, ETOH use,
8,9
Belief, relationship to , DSES • Existential well-being2,36
substance abuse,
1,2,15
attachment improved CD-4 count

• Health behaviors/choices
Religious or
• e.g., treatment adherence,
spiritual
coping4,5,7 substance use, etc.
• Health service utilization

Figure 3 Spirituality and health.

Abbreviations: DSES, Daily Spiritual Experience Scale; ETOH, ethyl alcohol.

impact insight, coping, and perceptions of need for treatment
or adherence; multiple factors such as side effects, attitudes to
medications, and medication costs could also influence adher-
ence; existing health services could benefit by incorporation
of medication-related targeted interventions.
Discussion
This project utilized a mixed-methods approach to explore the
impact of spirituality and its application to chronic integrated
care, with a focus on depression and HIV+/AIDS.
Spirituality and health
A combination of enhanced depression screening and recog-
nition, coping with illness, stress and trauma, health choices
and behaviors such as medication adherence, reduced sub-
stance seeking and use, as well as effects on immunologic,
physiological, and mental function, may facilitate improved
outcomes.43–45,53–56 Spirituality has been suggested to have a
positive impact on behaviors, coping, sense of well-being,
self-esteem, self-care, depression, anxiety, and substance
abuse43,53–56 and is associated with lower suicide rates.56,57
A growing body of literature supports a positive associa-
tion between spiritual attitudes,58 beliefs and practices59 and
mental health; HIV+ outcomes;43,60 as well as in mind–body
mechanisms and immunologic processes involved in both
HIV+ and depression.56
Through our literature review, it was evident that spiritual-
ity plays a role in adherence related to antiretrovirals. Most
reports showed a positive correlation between spirituality and
medication adherence, with only a few demonstrating faith
in God that is incompatible with illness acceptance and treat-
ment resulting in passivity and resistance. Spirituality could
help provide foundational support in managing therapies,
and in turn resulting in greater adherence as patients learn
to cope and find hope. Spirituality could perhaps serve as a
bridge to overcome barriers to care such as mistrust of the
health care system and stigma associated with chronic illness
and their specific medical conditions in settings such as the
study population, where there was more comfort speaking
about psychiatric symptoms in spirituality group. Some form
of assessment of individual faith-treatment congruence could
be beneficial to gauge if there are attitudes that would work
in support of or against treatment and medication adherence.
The majority of the studies identified from the literature
review assessed adherence in the HIV+/AIDS population,
not as many studied the depression population or those with
chronic mental illness. This is most likely due to the well-
known long-term commitment of ART and the importance of
adherence in preventing viral resistance.61 Patients who are
HIV+ and have a chronic mental disorder such as depression,
although vulnerable to poorer health outcomes, could benefit
from services that adequately detect and treat the mental
disorder as well as facilitate spiritual or religious coping.
Such coping, congruent with one’s perceptions or insight
into illness and treatment, may provide social support and
improve medication adherence. Spiritual or religious coping
could also help to overcome barriers to adherence such as
substance abuse and facilitate positive health behaviors. On

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Dovepress Spiritual care and mental health and medication adherence in HIV+ populations
the other hand, providers should consider taking into account
what strategies could be employed to identify and address
faith-treatment incongruence and any consequent adverse
health behaviors or treatment decisions. Processes to promote
patient illness and medication education, enhance medication
access, and perhaps discreet prescription delivery, individual
privacy, and ways to overcome stigma and shame could be
beneficial. Spirituality group or individual CMR sessions
could be a forum that some consider safe to reveal and dis-
cuss faith-treatment incongruence, negative consequences of
treatment non-adherence, and in an integrated care setting,
psychiatric consultant referral.
The demographics in most of the HIV+/AIDS studies
reviewed showed a disproportionate number of AAs com-
pared to other ethnic populations. Minority populations
both in the US and from other countries were found to rely
on spirituality more so than Caucasian populations.22 More
studies can be conducted to investigate this particular patient
population and gain a better understanding of their motiva-
tions and obstacles.
Figure 3 gives a proposed illustration of study population
spirituality and health. Private practices, spiritual experi-
ences, and spiritual or religious coping can all potentially
impact behaviors that could work along with or against
treatment adherence and outcomes. 43–45,55–57,60 Spiritual
experiences might help to evaluate positive experiences by
which spirituality may contribute to health outcomes. Faith
beliefs that do not produce these positive experiences or
compatible behaviors could result in poor or non-adherence
and suboptimal outcomes. In a patient with adversely impact-
ing spiritual beliefs, health behaviors and non-adherence
could produce a picture similar to untreated MDD in HIV+
depressed individuals (i.e., Figure 2). Individuals without
depression (without MDD) and treated depression (treated
MDD) had similar proportions of individuals who were non-
adherent to ART medications when compared to each other,
while those with untreated MDD had a higher proportion of
non-adherence.
The positive association between spiritual advisor and
MDD absence could suggest spirituality is protective against
MDD; although the impact of a spiritual advisor has not been
fully elucidated. Level of spirituality and connectedness with
a higher being or cause could be reflected in contact with
the advisor; or the advisor provides support and influence
that could help with positive emotions or impact behav-
ior. More research would be necessary to investigate any
possible association. The study did not include additional
information on spiritual advisor contacts after initial intake;
continuing impact, if any, is unknown and association with
HIV/AIDS - Research and Palliative Care 2017:9
depression outcomes could not be established. This could
also possibly be accounted for in the DSES, considered
to have scale items leaning more towards mental health
assessment than spirituality (personal communication, H
Koenig, November 2014).Lack of documented continuing
spiritual advisor contact; faith beliefs driving incompatible
or counterproductive behaviors to patient’s own health care
and incompatible behaviors that remain unaddressed by both
health providers and spiritual advisors could contribute to
nonadherence or poor outcomes. Furthermore, there could
be other contributory factors to treatment non-adherence,
which were not identified; spirituality assessment and CMR
as a routine part of care could be beneficial to identify these.
Overall, Figure 3 is intended to illustrate an opportunity
for positive impact of spirituality or religion on physical
and mental health. The DSES measures ordinary, or daily,
spiritual experiences as an everyday part of the individual’s
life.62 Figure 3 includes specific DSES items that scored high
in the study population, with specific corresponding DSES
item number(s) highlighted in superscript. Spirituality could
be reflected in belief, relationship to, and connection with
a source. Contact with a spiritual advisor could result from
individual spirituality or religious source or could be a part of
spiritual or religious practices, experiences, or coping. Health
behaviors, treatment adherence, and use of support and health
services could impact aspects of physical and mental health
such as immune function and psychiatric symptoms. Prior
work published by the investigators reported poor CD-4
count association with poor ART adherence and MDD, which
persists where MDD is untreated.5 Faith beliefs could be
assessed to help improve adherence and psychiatric symptom
treatment. Future research goals could include prospective
examination to serially measure spiritual or religious prac-
tices, spiritual advisor visits, and the relationship between
spiritual interventions and mental/physical health outcomes.
Conclusion
Assessment of and addressing spiritual or religious beliefs
could be beneficial to HIV+ individuals; more so if a chronic
mental disorder such as depression has also been identified.
Health care providers should screen and treat depression
in this patient population as well as collaborate with other
health and spiritual care providers to identify and address
spiritual needs to optimize health outcomes. Also, important
is an understanding of beliefs, behaviors, and medication
use processes that contribute to MRPs and non-adherence.
More research is warranted to understand the role of spiritu-
ality in mental health and medication adherence in chronic
conditions.
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Oji et al
Acknowledgments
This work was supported by pilot funds awarded to
Dr. Oji through a grant from the National Institutes of
Mental Health (NIMH) R25MH08066 and in part from
the National Institutes of Health (NIH) Contract No.
HH5N261200800001E awarded to Dr Evaristus Nwulia.
The content is solely the responsibility of the authors and
does not necessarily represent the official views or policies
of the NIMH or NIH Department of Health and Human
Services. The contributions of Dr Suad Kapetanovic, MD,
University of Southern California; Dr Patricia Noumedem,
PharmD, Howard University; also FMCS staff, especially
James Perry, CACI, are appreciated.
Disclosure
The authors report no conflicts of interest in this work.
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